NCG020190_SW Permit DOSA_20230911

R -s,
ROY COOPER .6;r f �.'l
Governor •-
ELIZABETH S.BISER ` ra+•
Secretary �'`' ,"r
DOUGLAS R.ANSEL NORTH CAROLINA
Interim Dlr, Environmental Quality
Stormwater Delegation of Signature Authority Form (DOSA)
This form shall be used to delegate signature authority from the permit Owner (Permittee) to
another party. Only the Responsible Official defined below may submit permit applications and
reports required by the permit (such as Data Monitoring Reports and Annual Reports) until this
form is completed and submitted to the DEMLR Stormwater Program. Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility and compliance for
permit compliance,
Permit Owner:The legal entity to which/whom a permit has been issued and may be an individual
or an organization such as a company or government agency. Every Owner is required to have a
Responsible Official who meets the legal signature authority requirements in 40 CFR 122.22,
summarized below:
• Fora corporation,the Responsible Official shall be a president,secretary,treasurer,or vice president
in charge of a principal business function,or another individual who performs similar functions for
the corporation,or the manager ofone or more manufacturing,production,or operating facilities
who is authorized to make management decisions about the facility operation.
• For a partnership or sole proprietorship,the Responsible Official shall be a general partner or the
proprietor,respectively;or
• For a municipality,State,Federal,or other public agency,the Responsible Official shall be either a
principal executive officer[City/County Manager]or ranking elected official[Mayor].
Please mail the DOSA Form with original wet signatures to: NCDEMLRStormwater
Program, 1612 MSC,Raleigh, NC 27699-1612
Name of Organizational Entity
Vulcan Construction Materials, LLC
Responsible Official Name
Jack Marsh
Responsible Official Title:
Vice President of Operations
Email Address Phone
[e-mail] 336-767-4600
Mailing Address
4401 N. Patterson Ave.
City State Zip code
Winston Salem NC 27105
D_E Q North Carolina Department of Environmental Quality Division of Energy Mineral and land Resources
512 North Salisbury Street 1612 Mail Service center Raleigh.North caroling 27699-1612
t �ds..\/'" 9'9'079200

A. Persons to Receive Signature Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
Attach additional pages if you need more space.
Delegated Party Name Tony Johnson
Delegated Party Title Environmental Engineer
Permit Number(s) Please See Attached Permit Numbers List
Email Address [e-mail] Phone [phone]
Mailing Address 11020 David Taylor Drive, Suite 400
City Charlotte State NC Zip code 28262
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
I Date Y'. #Z-3
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address: Phone
Mailing Address
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address Phone
Mailing Address
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 2

B. Responsible Official Signature
The Responsible Official,as identified in accordance with 40 CFR 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official,I, Jack Marsh (printed name),
have the authority to enter into this Agreement for
Vulcan Construction Materials, LLC _ (Owner/Organization Name).
I request that the DE MLR Stormwater Program include the persons listed in Part A of this
form signatory authority for the above-named permit.
I acknowledge that I,and the persons listed in Part A of this form work at/for my
organization and have authority to act as a signatory for purposes of the N CD EQ's
electronic document systems.
By submitting this application,1, Jack Marsh (printed name),have read,
understand,and accept the terms and conditions of the stormwater permit(s) for which I
am the Responsible Official.
fit sponsible Official Signature
Vice President of Operations Zp z3
Title Da,
Stormwater Permit Delegation of Signatory Authority Form
Page 3

Vulcan Construction Materials, LLC
North Carolina Delegation of Signature Authority Form
Permit Numbers
Quarry Permit No.
115 NCG020160
421 NCG020910
Boone NCG020251
Cabarrus NCG020172
Clear Creek NCG020201
East Forsyth NCG020115
Elkin NCG020159
Enka NCG020151
Gold Hill NCG020108
Hendersonville NCG020176
High Shoals NCG020190
Lenoir NCG020026
Morganton NCG020177
North NCG020082
Penrose NCG020046
Pineville NCG020049
Rockingham NCG020107
Rowan NCG020310
Smith Grove NCG020081
South Fork NCG020441
Spruce Pine NCG020511
Stokesdale NCG020191
Yadkin NCG020183
Burke NCG020691
North 321 NCG020863